Form W-9 - Wa



Substitute

Form |W-9 |Request for Taxpayer

Identification Number and Certification |Give form to the

requester. Do not

send to the IRS. | |

|(Rev. February 2005) | | |

|Plea|Name (as shown on your income tax return) |

|se | |

|prin| |

|t or| |

|type| |

|See | |

|Spec| |

|ific| |

|Inst| |

|ruct| |

|ions| |

|on | |

|page| |

|2. | |

| |      |

| |Business name, if different from above |

| |      |

| |Check | Individual/Sole Proprietor | Corporation | Partnership | |      |

| |appropriate | | | |Othe| |

| |box: | | | |r | |

| |Address (number, street, and apt. or suite no.) |Requester’s name and address (optional) |

| |      | |

| |City, state, and ZIP code | |

| |               | |

| |List account number(s) here |

| |    Ph # UBI #  |

|Part I |Taxpayer Identification Number (TIN) |

|Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 to avoid backup | |

|withholding. For individuals, this is your social security number (SSN). However, for a resident alien, sole | |

|proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer | |

|identification number (EIN). If you do not have a number, see How to get a TIN on page 3. | |

|Note: If the account is in more than one name, see the chart on page 3 for guidelines on whose number | |

|to enter. | |

| |Social security number |

| |  |

| | |

| |Employer identification number |

| |  |

|Part II |Certification |

|Under penalties of perjury, I certify that: |

|The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and |

|I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service |

|(IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no |

|longer subject to backup withholding, and |

|I am a U.S. person (including a U.S. resident alien). |

|Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding |

|because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. |

|For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement |

|(IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must |

|provide your correct TIN. (See the instructions on page 3.) |

|Sign Here |Signature of |Date ►       |

| |U.S. person ► | |

|Purpose of Form |Nonresident alien who becomes a resident alien. Generally, only a nonresident|

|A person who is required to file an information return with the IRS must |alien individual may use the terms of a tax treaty to reduce or eliminate |

|obtain your correct taxpayer identification number (TIN) to report, for |U.S. tax on certain types of income. However, most tax treaties contain a |

|example, income paid to you, real estate transactions, mortgage interest you |provision known as a “saving clause.” Exceptions specified in the saving |

|paid, acquisition or abandonment of secured property, cancellation of debt, |clause may permit an exemption from tax to continue for certain types of |

|or contributions you made to an IRA. |income even after the recipient has otherwise become a U.S. resident alien |

|U.S. person. Use form W-9 only if you are a U.S. person (including a resident|for tax purposes. |

|alien), to provide your correct TIN to the person requesting it (the |If you are a U.S. resident alien who is relying on a exception contained in |

|requester) and, when applicable, to: |the saving clause of a tax treaty to claim an exemption from U.S. tax on |

|Certify the TIN you are giving is correct (or you are waiting for a number to|certain types of income, you must attach a statement to Form W-9 that |

|be issued), |specifies the following five items: |

|Certify you are not subject to backup withholding, or |The treaty country. Generally, this must be the same treaty under which you |

|Claim exemption from backup withholding if you are a U.S. exempt payee. |claimed exemption from tax as a nonresident alien. |

|Note: If a requester gives you a form other than Form W-9 to request your |The treaty article addressing the income. |

|TIN, you must use the requester’s form if it is substantially similar to this|The article number (or location) in the tax treaty that contains the saving |

|Form W-9. |clause and its exceptions. |

|For federal tax purposes you are considered a person if you are: |The type and amount of income that qualifies for the exemption from tax. |

|An individual who is a citizen or resident of the United States, |Sufficient facts to justify the exemption from tax under the terms of the |

|A partnership, corporation, company, or association created or organized in |treaty article. |

|the United States or under the laws of the United States, or |Example. Article 20 of the U.S.-China income tax treaty allows an exemption |

|Any estate (other than a foreign estate) or trust. See Regulations sections |from tax for scholarship income received by a Chinese student temporarily |

|301.7701-6(a) and 7(a) for additional information. |present in the United States. Under U.S. law, this student will become a |

|Foreign person. If you are a foreign person, do not use For W-9. Instead use |resident alien for tax purposes if his or her stay in the United States |

|the appropriate Form W-8 (see Publication 515, Withholding of Tax on |exceeds 5 calendar years. However, paragraph 2 of the first Protocol to the |

|Nonresident Aliens and Foreign Entities). |U.S.-China treaty (dated April 30, 1984) allows the provisions of Article 20 |

| |to continue to apply even after the Chinese student becomes a resident alien |

| |of the United States. A Chinese |

| |Substitute Form W-9 (Rev. 02-2005) |

|student who qualifies for this exception (under paragraph 2 of the first |your filing (sole proprietor, corporation, etc.), then check the box for |

|protocol) and is relying on this exception to claim an exemption from tax on |“Other” and enter “LLC” in the space provided. |

|his or her scholarship or fellowship income would attach to Form W-9 a |Other entities. Enter your business name as shown on required Federal tax |

|statement that includes the information described above to support that |documents on the “Name” line. This name should match the name shown on the |

|exemption. |charter or other legal document creating the entity. You may enter any |

|If you are a nonresident alien or a foreign entity not subject to backup |business, trade, or DBA name on the “Business name” line. |

|withholding, give the requester the appropriate completed form W-8. |Note: You are requested to check the appropriate box for your status |

|What is backup withholding? Persons making certain payments to you must under|(individual/sole proprietor, corporation, etc.). |

|certain conditions withhold and pay to the IRS 28% of such payments (after |Exempt from backup withholding |

|December 31, 2002). This is called “backup withholding.” Payments that may be|If you are exempt, enter your name as described above and check the |

|subject to backup withholding include interest, dividends, broker and barter |appropriate box for your status, then check the “Exempt from backup |

|exchange transactions, rents, royalties, non-employee pay, and certain |withholding” box in the line following the business name, sign and date the |

|payments from fishing boat operators. Real estate transactions are not |form. |

|subject to backup withholding. |Generally, individuals (including sole proprietors) are not exempt from |

|You will not be subject to backup withholding on payments you receive if you |backup withholding. Corporations are exempt from backup withholding for |

|give the requester your correct TIN, make the proper certifications, and |certain payments, such as interest and dividends. |

|report all your taxable interest and dividends on your tax return. |Note: If you are exempt from backup withholding, you should still complete |

|Payments you receive will be subject to backup withholding if: |this form to avoid possible erroneous backup withholding. |

|You do not furnish your TIN to the requester, or |Exempt payees. Backup withholding is not required on any payments made to the|

|You do not certify your TIN when required (see the Part II instructions on |following payees: |

|page 3 for details), or |An organization exempt from tax under section 501(a), any IRA, or a custodial|

|The IRS tells the requester that you furnished an incorrect TIN, or |account under section 403(b)(7) if the account satisfies the requirements of |

|The IRS tells you that you are subject to backup withholding because you did |section 401(f)(2); |

|not report all your interest and dividends on your tax return (for reportable|The United States or any of its agencies or instrumentalities; |

|interest and dividends only), or |A state, the District of Columbia, a possession of the United States, or any |

|You do not certify to the requester that you are not subject to backup |of their political subdivisions or instrumentalities. |

|withholding under 4 above (for reportable interest and dividend accounts |A foreign government or any of its political subdivisions, agencies, or |

|opened after 1983 only). |instrumentalities; or |

|Certain payees and payments are exempt from backup withholding. See the |An international organization or any of its agencies or instrumentalities. |

|instructions below and the separate Instructions for the Requester of Form |Other payees that may be exempt from backup withholding include: |

|W-9. |A corporation; |

|Penalties |A foreign central bank of issue; |

|Failure to furnish TIN. If you fail to furnish your correct TIN to a |A dealer in securities or commodities required to register in the United |

|requester, you are subject to a penalty of $50 for each such failure unless |States, the District of Columbia, or a possession of the United States; |

|your failure is due to reasonable cause and not to willful neglect. |A futures commission merchant registered with the Commodity Futures Trading |

|Civil penalty for false information with respect to withholding. If you make |Commission; |

|a false statement with no reasonable basis that results in no backup |A real estate investment trust; |

|withholding, you are subject to a $500 penalty. |An entity registered at all times during the tax year under the Investment |

|Criminal penalty for falsifying information. Willfully falsifying |Company Act of 1940; |

|certifications or affirmations may subject you to criminal penalties |A common trust fund operated by a bank under section 584(a); |

|including fines and/or imprisonment. |A financial institution; |

|Misuse of TINs. If the requester discloses or uses TINs in violation of |A middleman known in the investment community as a nominee or custodian; or |

|Federal law, the requester may be subject to civil and criminal penalties. |A trust exempt from tax under section 664 or described in section 4947. |

|Specific Instructions |The chart below shows types of payments that may be exempt from backup |

|Name |withholding. The chart applies to the exempt recipients listed above, 1 |

|If you are an individual, you must generally enter the name shown on your |through 15. |

|social security card. However, if you have changed your last name, for |If the payment is for… |

|instance, due to marriage without informing the Social Security |THEN the payment is exempt for… |

|Administration of the name change, enter your first name, the last name shown| |

|on your social security card, and your new last name. |Interest and dividend payments |

|If the account is in joint names, list first, and then circle the name of the|All exempt recipients except for 9 |

|person or entity whose number you enter in Part I of the form. | |

|Sole proprietor. Enter your individual name as shown on your social security |Broker transactions |

|card on the “Name” line. You may enter your business, trade, or “doing |Exempt recipients 1 through 13. Also, a person registered under the |

|business as (DBA)” name on the “Business name” line. |Investment Advisers Act of 1940 who regularly acts as a broker |

|name” line. | |

|Limited liability company (LLC). If you are a single-member LLC (including a |Barter exchange transactions and patronage dividends |

|foreign LLC with a domestic owner) that is disregarded as an entity separate |Exempt recipients 1 through 5 |

|from its owner under Treasury regulations section 301.7701-3, enter the | |

|owner’s name on the “Name” line. Enter the LLC’s name on the “Business name” |Payments over $600 required to be reported and direct sales over $5,000 1 |

|line. Check the appropriate box for |Generally, exempt recipients 1 through 7 2 |

| | |

| |1 See Form 1099-MISC, Miscellaneous Income, and its instructions. |

| |2 However, the following payments made to a corporation (including gross |

| |proceeds paid to an attorney under section 6045(f), even if the attorney is a|

| |corporation) and reportable on Form 1099-MISC are not exempt from backup |

| |withholding: medical and health care payments, attorneys’ fees; and payments |

| |for services paid by a Federal executive agency. |

| | |

|Substitute Form W-9 (Rev. 02-2005) |Page 2 |

|Part I. Taxpayer Identification Number (TIN) |Other payments. You must give your correct TIN, but you do not have to sign |

|Enter your TIN in the appropriate box. If you are a resident alien and you do|the certification unless you have been notified that you have previously |

|not have and are not eligible to get an SSN, your TIN is your IRS individual |given an incorrect TIN. “Other payments” include payments made in the course |

|taxpayer identification number (ITIN). Enter it in the social security number|of the requester’s trade or business for rents, royalties, goods (other than |

|box. If you do not have an ITIN, see How to get a TIN below. |bills for merchandise), medical and health care services (including payments |

|If you are a sole proprietor and you have an EIN, you may enter either your |to corporations), payments to a non-employee for services, payments to |

|SSN or EIN. However, the IRS prefers that you use your SSN. |certain fishing boat crew members and fishermen, and gross proceeds paid to |

|If you are a single-owner LLC that is disregarded as an entity separate from |attorneys (including payments to corporations). |

|its owner (see Limited liability company (LLC) on page 2), enter your SSN (or|Mortgage interest paid by you, acquisition or abandonment of secured |

|EIN, if you have one). If the LLC is a corporation, partnership, etc., enter |property, cancellation of debt, qualified tuition program payments (under |

|the entity’s EIN. |section 529), IRA, Coverdell ESA, Archer MSA or HSA contributions or |

|Note: See the chart on this page for further clarification of name and TIN |distributions, and pension distributions. You must give your correct TIN, but|

|combinations. |you do not have to sign the certification. |

|How to get a TIN. If you do not have a TIN, apply for one immediately. To |What Name and Number To Give the Requester |

|apply for an SSN, get Form SS-5, Application for a Social Security Card, from|For this type of account: |

|your local Social Security Administration office or get this form online at |Give name and SSN of: |

|online/ss5.pdf. You may also get this form by calling | |

|1-800-772-1213. Use Form W-7, Application for IRS Individual Taxpayer |1. |

|Identification Number, to apply for an ITIN or Form SS-4, Application for |Individual |

|Employer Identification Number, to apply for an EIN. You can apply for an EIN|The individual |

|online by accessing the IRS website at businesses/ and clicking | |

|on Employer ID Numbers under Related Topics. You can get Forms W-7 and SS-4 |2. |

|from the IRS by visiting or by calling 1-800-TAX-FORM |Two or more individuals (joint account) |

|(1-800-829-3676). |The actual owner of the account or, if combined funds, the first individual |

|If you are asked to complete Form W-9 but do not have a TIN, write “Applied |on the account 1 |

|For” in the space for the TIN, sign and date the form, and give it to the | |

|requester. For interest and dividend payments, and certain payments made with|3. |

|respect to readily tradable instruments, generally you will have 60 days to |Custodian account of a minor (Uniform Gift to Minors Act) |

|get a TIN and give it to the requester before you are subject to backup |The Minor 2 |

|withholding on payments. The 60-day rule does not apply to other types of | |

|payments. You will be subject to backup withholding on all such payments |4. |

|until you provide your TIN to the requester. |a. |

|Note: Writing “Applied For” means that you have already applied for a TIN or |The usual revocable savings trust (grantor is also trustee) |

|that you intend to apply for one soon. |The grantor-trustee 1 |

|Caution: A disregarded domestic entity that has a foreign owner must use the | |

|appropriate Form W-8. | |

|Part II. Certification |b. |

|To establish to the withholding agent that you are a U.S. person, or resident|So-called trust account that is not a legal or valid trust under state law |

|alien, sign Form W-9. You may be requested to sign by the withholding agent |The actual owner 1 |

|even if items 1, 4, and 5 below indicate otherwise. | |

|For a joint account, only the person whose TIN is shown in Part I should sign|5. |

|(when required). Exempt recipients, see Exempt from backup withholding on |Sole proprietorship or |

|page 2. |single-owner LLC |

|Signature requirements. Complete the certification as indicated in 1 through |The owner 3 |

|5 below. | |

|Interest, dividend, and barter exchange accounts opened before 1984 and |For this type of account: |

|broker accounts considered active during 1983. You must give your correct |Give name and EIN of: |

|TIN, but you do not have to sign the certification. | |

|Interest, dividend, broker, and barter exchange accounts opened after 1983 |6. |

|and broker accounts considered inactive during 1983. You must sign the |Sole Proprietorship or |

|certification or backup withholding will apply. If you are subject to backup |single-owner LLC |

|withholding and you are merely providing your correct TIN to the requester, |The owner 3 |

|you must cross out item 2 in the certification before signing the form. | |

|Real estate transactions. You must sign the certification. You may cross out |7. |

|item 2 of the certification. |A valid trust, estate, or pension trust |

| |Legal entity 4 |

| | |

| |8. |

| |Corporate or LLC electing corporate status on Form 8832 |

| |The corporation |

| | |

| |9. |

| |Association, club, religious, charitable, educational, or other tax-exempt |

| |organization |

| |The organization |

| | |

| |10. |

| |Partnership or multi-member LLC |

| |The partnership |

| | |

| |11. |

| |A broker or registered nominee |

| |The broker or nominee |

| | |

| |12. |

| |Account with the Department of Agriculture in the name of a public entity |

| |(such as a state or local government, school district, or prison) that |

| |receives agricultural program payments |

| |The public entity |

| | |

| |1 List first and circle the name of the person whose number you furnish. If |

| |only one person on a joint account has an SSN, that person’s number must be |

| |furnished. |

| |2 Circle the minor’s name and furnish the minor’s SSN. |

| |3 You must show your individual name, but you may also enter your business or|

| |“DBA” name. You may use either your SSN or your EIN (if you have one). |

| |4 List first and circle the name of the legal trust, estate, or pension |

| |trust. (Do not furnish the TIN of the personal representative or trustee |

| |unless the legal entity itself is not designated in the account title.) |

| |Note: If no name is circled when more than one name is listed, the number |

| |will be considered to be that of the first name listed. |

| | |

|Privacy Act Notice |

|Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons who must file information returns with the IRS to report |

|interest, dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or abandonment of secured property, cancellation of |

|debt, or contributions you made to an IRA or Archer MSA. The IRS uses the numbers for identification purposes and to help verify the accuracy of your tax |

|return. The IRS may also provide this information to the Department of Justice for civil and criminal litigation, and to cities, states, and the District |

|of Columbia to carry out their tax laws. We may also disclose this information to other countries under a tax treaty, or to other Federal and state |

|agencies to enforce Federal nontax criminal laws and to combat terrorism. |

|You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold 30% of taxable interest, dividend, and |

|certain other payments to a payee who does not give a TIN to a payer. Certain penalties may also apply. |

|Substitute Form W-9 (Rev. 02-2005) |Page 3 |

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